How best to manage dysfunctional uterine bleeding

,; ,; ,

Applied Evidence

How best to manage dysfunctional uterine bleeding

J Fam Pract. 2010 August;59(8):449-458

By

Avinash Reddy, MD

David L. Maness, DO, MSS

Carolyn L. Harraway-Smith, MD

Irregular or unusually heavy periods are a common complaint. Most often, the condition is benign and can by managed conservatively.

PDF Download

References

1. Wren BG. Dysfunctional uterine bleeding. Aust Fam Physician. 1998;27:371-377.

2. Astrup K, Olivarius Nde F. Frequency of spontaneously occurring postmenopausal bleeding in the general population. Acta Obstet Gynecol Scand. 2004;83:203-207.

3. Albers JR, Hull SJ, Wesley RM. Abnormal uterine bleeding. Am Fam Physician. 2004;69:1916-1926.

4. Munster K, Schmidt L, Helm P. Length and variation in the menstrual cycle—a cross-sectional study from a Danish country. Br J Obstet Gynaecol. 1992;99:422-429.

5. Halberg L, Hogdahl AM, Nilsson L, et al. Menstrual blood loss-a population study. Acta Obstet Gynecol Scand. 1966;45:320-351.

6. Warner PE, Critchley HO, Lumsden MA, et al. Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. Am J Obstet Gynecol. 2004;190:1216-1223.

7. Hill NC, Oppenheimer LW, Morton KE. The aetiology of vaginal bleeding in children. A 20-year review. Br J Obstet Gynaecol. 1989;96:467-470.

8. Amman M, Anguino H, Bauman RA, et al. Postmenopausal uterine bleeding. Pasadena, Calif: Kaiser Permanente Southern California; December 2006. NGC 005688. Available at: www.guideline.gov. Accessed July 19, 2010.

9. Hataska H. The evaluation of abnormal uterine bleeding. Clin Obstet Gynecol. 2005;48:258-273.

10. Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006;(2):CD003855.-

11. Amman M, Anguino H, Bauman RA, et al. Chronic abnormal uterine bleeding in nongravid women. Pasadena, Calif: Kaiser Permanente Southern California; December 2006. NGC 005687. Available at: www.guideline.gov. Accessed July 19, 2010.

12. Bradley LD, Widrich T. State-of-the-art flexible hysteroscopy for office gynecologic evaluation. J Am Assoc Gynecol Laparosc. 1995;2:263-267.

13. Nagele F, O’Connor H, Davies A, et al. 2500 outpatient diagnostic hysteroscopies. Obstet Gynecol. 1996;88:87-92.

14. Serden SP. Diagnostic hysteroscopy to evaluate the cause of abnormal uterine bleeding. Obstet Gynecol Clin North Am. 2000;27:277-286.

15. Shwayder JM. Pathophysiology of abnormal uterine bleeding. Obstet Gynecol Clin North Am. 2000;27:219-234.

16. Vilos GA, Lefebvre G, Graves GR. Guidelines for the management of abnormal uterine bleeding. SOGC Clinical Practice Guidelines; August 2001. Available at: www.sogc.org/guidelines/public/106E-CPG-August2001.pdf. Accessed July 19, 2010.

17. Rosenthal AN, Panoskaltsis T, Smith T, et al. The frequency of significant pathology in women attending a general gynaecological service for postcoital bleeding. BJOG. 2001;108:103-106.

18. Beers MH, Berkow R. eds. Dysfunctional uterine bleeding, In: The Merck Manual. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999:1941-1942.

19. Singh RH, Blumenthal P. Hormonal management of abnormal uterine bleeding. Clin Obstet Gynecol. 2005;48:337-352.

20. Edlund M, Blomback M, von Schoultz B, et al. On the value of menorrhagia as a predictor for coagulation disorders. Am J Hematol. 1996;53:234-238.

21. Kouides PA. Evaluation of abnormal bleeding in women. Curr Hematol Rep. 2002;1:11-18.

22. Kadir RA, Economides DL, Sabin CA, et al. Frequency of inherited bleeding disorders in women with menorrhagia. Lancet. 1998;351:485-489.

23. Dilley A, Drews C, Miller C, et al. von Willebrand disease and other inherited bleeding disorders in women with diagnosed menorrhagia. Obstet Gynecol. 2001;97:630-636.

24. Ries LAG, Melbert D, Krapcho M, et al. eds SEER Cancer Statistics Review, 1975-2005.Bethesda, Md: National Cancer Institute. http://seer.cancer.gov/csr/1975_2005/, based on November 2007 SEER data submission, posted to the SEER web site, 2008. Accessed July 19, 2010.

25. Ehrmann DA. Polycystic ovary syndrome. N Engl J Med. 2005;352:1223-1226.

26. Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding. A Nordic multicenter study. Am J Obstet Gynecol. 1995;172:1488-1494.

27. Tabor A, Watt HC, Wald NJ. Endometrial thickness as a test for endometrial cancer in women with postmenopausal bleeding. Obstet Gynecol. 2002;99:663-670.

28. Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA. 1998;280:1510-1517.

29. Medverd JR, Dubinsky TJ. Cost analysis model: US versus endometrial biopsy in evaluation of peri- and post-menopausal abnormal vaginal bleeding. Radiology. 2002;222:619-627.

30. Scott S. Abnormal bleeding in the pediatric patient. Postgrad Obstet Gynecol. 2006;26:1-5.

31. Lethaby A, Irvine G, Cameron I. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(2):CD001016.-

32. Lethaby A, Irvine G, Cameron I. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2008;(1):CD001016.-

33. Stewart A, Cummins C, Gold L, et al. The effectiveness of levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review. Br J Obstet Gynaecol. 2001;108:74-86.

34. Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(4):CD000249.-

35. Beaumont H, Augood C, Duckitt K, et al. Danazol for heavy menstrual bleeding. Cochrane Database Syst Rev. 2002;(2):CD001017.-

36. Wellington K, Wagstaff AJ. Tranexamic acid: a review of its use in the management of menorrhagia. Drugs. 2003;63:1417-1433.

PRACTICE RECOMMENDATIONS

• Assess postmenopausal women for cancer by endometrial biopsy, transvaginal ultrasound, or saline infusion sonohysterogram. A

• Treat mild dysfunctional uterine bleeding (DUB) with nonsteroidal anti-inflammatory drugs, levonorgestrel intrauterine device (IUD), or danazol. A

• Treat moderate DUB with oral contraceptive pills C, levonorgestrel IUD, danazol, or tranexamic acid. A

• Treat severe DUB with the same agents used for moderate DUB, or with IV estrogen followed by oral contraceptive pills. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Test your skills: How would you treat these 3 patients?

CASE 1: Casey is a 14-year-old with a normal body mass index who has had heavy vaginal bleeding for 10 days. For the last 3 days, the bleeding has been so heavy she has been soaking more than 15 pads a day. She feels tired and is light-headed and dizzy when she stands up. Casey had her first period 13 months ago. Since then, her periods have varied in length from 18 to 40 days, with heavy bleeding for 7 to 14 days. She tells you she is not taking any prescription or herbal medications or over-the-counter supplements, and does not have any other medical problems. She is not sexually active. Her physical examination was remarkable only for pale skin and a positive tilt test. She feels frustrated and wants something done immediately.

CASE 2: Sarah is a 35-year-old obese woman whose chief complaint is irregular periods. For the past 3 years, she has had only 3 to 6 periods per year, each period lasting for 3 to 10 days. Her most recent period was 4 months ago. Sarah has a moderate amount of acne and facial hair.

CASE 3: Joan is a 53-year-old postmenopausal woman who has never been pregnant. She has a history of type 2 diabetes mellitus, hypertension, and obesity. She has come to your office for a routine physical examination. She tells you that her periods were regular until she stopped menstruating 4 years ago. But for the past 6 to 8 months she says she’s had irregular bleeding every 30 to 45 days, each period of bleeding lasting for 3 to 7 days. Her previous Pap smears and mammograms were normal. She has no family history of breast, gastrointestinal, or genital tract cancer. Her physical examination, including her pelvic examination, is negative.

These 3 women are fairly typical patients in a family medicine practice. Most women experience episodes of abnormal uterine bleeding (AUB) at some point in their reproductive lives. The condition occurs in approximately 1 in every 3 women of reproductive age and 1 in 10 postmenopausal women, and the impact on quality of life is often substantial.^1,2 Abnormal bleeding can be divided into 4 major categories: genital tract pathology, systemic disease, exposure to medication or radiation, and dysfunctional uterine bleeding (DUB). Specific conditions within each category are listed in TABLE 1. The focus of this article will be on DUB, the category that remains after the other possibilities are excluded.

First, find out what your patient means by “abnormal”
A normal menstrual cycle varies in length between 24 and 35 days, with menstrual flow lasting 2 to 7 days. Blood loss of 30 to 80 cc per cycle is considered normal.^3-5 To quantify blood loss, ask the patient how many pads or tampons she uses each period (<21 would be normal), how often she has to change pads (every 3 hours is usual), the size of clots (less than 1 cm is normal), and whether she has to get up at night to change pads.⁶ If blood loss is sufficient to cause anemia, the condition is always considered abnormal and requires further evaluation. When your patient’s description leaves you in doubt about whether her bleeding is abnormal, base your evaluation and treatment on her perception of a change in her menstrual cycle.

FAST TRACK

To quantify blood loss, find out how many pads or tampons the patient uses and how often she changes them, the size of clots, and whether she has to get up at night to change pads.

Stages of the reproductive life cycle
The meaning of abnormal bleeding varies with your patient’s stage in her reproductive life cycle. Uterine bleeding in a premenarchal child or a postmenopausal woman is always abnormal and must be evaluated.^7-9

Premenarchal children with vaginal bleeding should be evaluated for trauma, sexual or physical abuse, foreign bodies, signs of precocious puberty, and possible infectious etiologies.⁷ If the cause of the bleeding is not obvious, these patients should be immediately referred to a pediatric gynecologist.